Provider Demographics
NPI:1770629297
Name:JERYLO, CARRIE LATVALA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LATVALA
Last Name:JERYLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JEAN
Other - Last Name:LATVALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14060 AZTEC ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-7443
Mailing Address - Country:US
Mailing Address - Phone:763-422-1392
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW
Practice Address - Street 2:SUITE 310
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5853
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:763-755-4261
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6292235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN131G3JEOtherBLUECROSSBLUESHIELD
MNHP34823OtherHEALTHPARTNERS
MN46-00854OtherMEDICA